Re: Measuring Fatal Neglect

[Howard Dubowitz <hdubowit@xxxxxxxxxxxxx>]

Hi, here are some thoughts on fatal neglect. My experience from
Maryland's Child Fatality Review Team is that there is a strong
reluctance to label many deaths due to lapses in supervision as "neglect",
and pile on a grieving family.  Instead, there is an inclination to view
most such lapses as "only human" and avoid the blaming connotations of
neglect. So, there's a need for caution in interpreting how such cases are
coded by CFR teams.

One approach is to define neglect in terms of the child's basic needs not
being met, rather than focusing on parental omissions in care. This is not
to suggest that parental behavior is irrevelent, rather that it's often
part of a larger complex picture.  So step one could be determining if,
for example, a child's need for protection from environmental hazards (in
and out the home) were adequately met.  For the infant alone in the tub or
the 9 year old with access to a loaded gun, clearly the answer would be
no.  Determining the adequacy of care hinges on a few things:
	- epidemiological data re risks of certain exposures/conditions
	- knowledge of individual child (eg, severe asthmatic's need for
meds) 
	- specific circumstances of case (eg, where was gun)

No easy formula is likely, and clearly these situations exist on
a continuum ranging from wonderful to terribly inadequate care of the
child's basic needs.

The second step could tackle determination of what contributed to the
neglect fatality. Here there's a need to broadly consider potential
contributors (eg, child, parent, family, community and other factors); it
can be tricky to weigh their degree of influence, especially when multiple
and interacting factors are contributory. CPS usually
focuses on whether "a reasonable lay person" would have recognized the
need for care, and intervened appropriately.  If it doesn't meet this
litmus test, they generally don't hold the caregiver responsible, and
don't consider the case neglect.  Also, a pattern of inadequate care is
considered more serious than a "single lapse".  

Hope this helps,
Howard Dubowitz 
 
On Mon, 12 Jul 1999 Lisa_Sanbonmatsu/Student/KSG@ksg.harvard.edu wrote:
> I am a doctoral student trying to develop a proxy for neglect fatalities using
> death certificate data (International Classification of Diseases-9th Revision).
> This is similar to McClain et al.?s (1993)  work except that I am focusing
> specifically on neglect.  Does anyone have any suggestions concerning diagnoses
> that may be indicative of fatal neglect?
> 
> Currently, I am focusing on fatalities that may involve 1) inadequate
> supervision (i.e., a toddler struck by a car, a young child who falls out of a
> window, a young child who chokes to death), 2) lack of medical care (i.e.,
> deaths due to medical conditions which are generally treatable), or 3) physical
> neglect (i.e., deaths from exposure or malnutrition).
> 
> I am hoping that by using specific diagnoses and age ranges, I will be able to
> develop a rough measure of fatal neglect.  However, there are numerous
> obstacles.  Some stem from the difficulty of separating out neglect deaths from
> both abuse deaths (deliberate withholding of food, physical abuse injuries
> falsely attributed to an accident, etc.) and from deaths that have little to do
> with a caretakers? actions (deaths due to unforeseeable events, environmental
> hazards, or congenital conditions).  Other difficulties arise from the variation
> in coding across states.
> 
> Any thoughts?  Does anyone know a member of a child death review team who might
> be willing to be interviewed about the decision making process?
> 
> Thank you.
> 
> 
> Lisa Sanbonmatsu
> Malcolm Wiener Center for Social Policy
> 79 JFK Street
> Harvard University
> Cambridge, MA 02138
> sanbonm@ksg.harvard.edu
> (617) 495-5131
> 
> 
> References
> 
> Margolin, L. (1990).  Fatal Child Neglect.  Child Welfare, 69 (4), 309-319.
> 
> McClain, P.W., Sacks, J.J., Froehlke, R.G., & Ewigman, B.G. (1993).  Estimates
> of fatal child abuse and neglect, United States, 1979 through 1988.  Pediatrics,
> 91, 338-343.
> 
> U.S. Advisory Board on Child Abuse and Neglect.  (1995).  A Nation?s Shame:
> Fatal Child Abuse and Neglect in the United States.  Washington, DC:  U.S.
> Department of Health and Human Services.
> 
> 
> 
> 

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Howard Dubowitz, MD, MS			        (410)706-6144 (voice mail)	
Professor of Pediatrics				(410)706-5289 (secretary)
University of Maryland School of Medicine	(410)706-0653 (FAX)
700 W. Lombard St., Baltimore, MD 21201          hdubowit@umaryland.edu
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